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BIOLIFE ORIGINAL ARTICLE

Study of electrocardiogram in competitive athletes

Samir Rafla1, Tarek Elzawawy2, Gamal Abd Elnaser Mahmoud3, Mohamed Sadaka4
and Ahmed Abdel Salam5
1,2,4 ,5
Cardiology Department Faculty of Medicine University of Alexandria, Egypt
3
Biological Sciences and Sports Health Faculty of Sports, University of Alexandria, Egypt

Email: dr.nassar87@gmail.com

ABSTRACT
Background: Sudden death in athletes is a major concern; the predictors and value of prior investigations
remain to be settled. The work aims at studying electrocardiograms (ECG) in competitive athletes to define
incidence of abnormalities and any relevant associations.
Methods: The study included hundred persons engaged in competitive sports for duration not less than 6
months; with training at least 3 days per week and at least two hours per day. Full history especially questioning
for syncope, tachycardias or chest pain was obtained as well as family history of sudden death or coronary
disease; examination for BP, any cardiac murmurs or arrhythmia. ECG was done for all plus echo Doppler in
some cases.
Results: During the period from 1/1/2015 to 1/10/2016, 100 athletes were screened by ECG, 54 played isotonic
sport while 46 were on isometric sport. Types of sports: isometric (static) (body builders) 46. Isotonic (dynamic)
54 (Bicycling 6, Football 15, Tennis 3, Basketball 16, Volleyball 8, Swimming 4, Boxing 2) . Echo was done in 15,
increase in LV size was found in 5 (Diastolic diameter up to 61mm). Follow up by telephone questionnaire was
done for all, 5 persons were re-examined after months, no abnormal events were found. Results: Data given
total then in isometric (static) group then isotonic (dynamic) group then P value respectively: LV hypertrophy by
voltage criteria 18%, 24%, 10.9%, p 0.087. Early repolarization in 5%, 9.3%, 0%, P 0.06. RSR' in V1 (and V2 in
some cases) 14%, 20%, 6.5%, P 0.047. Inverted T 3%, 3.7%, 2%, P =1. Total ECG changes of any form 43%, 59%,
23.9%, P 0.001. The significance of finding more ECG changes in isometric (static) athletes is not clear but
clinically did not show any effect. Correlation between the 18 athletes with ECG LVH and echocardiography: only
5 of the 18 showed increased diameters by echo but within accepted athletic heart criteria. Two of body builders
confessed of taking doping drugs (male hormones) but no clinical abnormal signs were detected. No long QT
was found.
Discussion: We did not find cases of hypertrophic cardiomyopathy, valvular heart disease, arrhythmogenic
syndromes or congenital heart disease. Conclusions: Routine ECG for all competitive athletes is not
recommended, it is only indicated if persons have symptoms as syncope or chest pain or tachyarrhythmia.
Key words: ECG , athletes, SCD.

Sudden cardiac death (SCD) associated with athletic

INTRODUCTION activity is a rare but results in significant public and
media attention (Chaitman 2007).
The competitive athlete has been described as one
who participates in an organized team or individual sport
requiring systematic training and regular competition How to Site This Article:
against others. The purpose of screening, as described Samir Rafla, Tarek Elzawawy, Gamal Abd Elnaser
here, is to provide medical clearance for participation in Mahmoud, Mohamed Sadaka and Ahmed Abdel Salam
competitive sports through routine and systematic (2017). Study of electrocardiogram in competitive
evaluations intended to identify clinically relevant and athletes. Biolife. 5(4), pp 474-478.
preexisting cardiovascular abnormalities and thereby doi:10.17812/blj.2017.5410.
reduce the risks associated with organized sports.
(Maron, Thompson et al. 1996, Maron, Thompson et al. Received: 19 August 2017; Accepted: 21 September, 2017;
2007). Published online: 23 October, 2017

474| © www.globalsciencepg.org Biolife | 2017 | Vol 5 | Issue 4

Samir Rafla et al Copyright@2017

Sports are classified into isotonic and isometric Clinical examination

sports. Sports characterized by relatively pure isotonic Examination for BP, any cardiac murmurs or
stress include long-distance running, soccer, and cross- arrhythmia. Weight and height to calculate body mass
country skiing. Relatively pure isometric stress sports index.
include weightlifting, martial arts, and track and field
throwing events. Athletes participating in these “pure Table-1. Classification of abnormalities of the
stress” sporting disciplines have been used to define the athlete's electrocardiogram(Corrado, Biffi et al. 2009)
concept of sports-specific exercise-induced cardiac
remodeling. Group 1: common and Group 2: uncommon and
Isotonic stress stimulates a form of exercise-induced training-related ECG training-unrelated ECG
remodeling characterized by biventricular dilation, biatrial changes changes
dilation, and enhanced left ventricular diastolic
Sinus bradycardia T-wave inversion
function.(Kovacs and Baggish 2016).
In contrast, isometric stress stimulates remodeling First-degree AV block ST-segment depression
confined to the left ventricle that is typically characterized Incomplete RBBB Pathological Q-waves
by mild degrees of concentric left ventricular hypertrophy Early repolarization Left atrial enlargement
with unchanged or relative impairment of diastolic Isolated QRS voltage
function. It is noteworthy that many of the most popular Left-axis deviation/left
criteria for left ventricular
sports involve significant amounts of both isotonic and anterior hemiblock
hypertrophy
isometric cardiovascular stress. As anticipated, Right-axis deviation/left
individuals who participate in “physiology overlap sports” posterior hemiblock
(i.e., concomitant high isometric/high isotonic) including Right ventricular
competitive cycling and rowing typically demonstrate the hypertrophy
most robust cardiac adaptations with elements of both
pressure- and volume-mediated remodeling.(Kovacs and Ventricular pre-excitation
Baggish 2016). Complete LBBB or RBBB
These physiological ECG changes should be clearly
separated from uncommon (<5%) and training-unrelated Long- or short-QT interval
ECG patterns such as ST-T repolarization abnormalities,
Brugada-like early
pathological Q-waves, left-axis deviation, intraventricular
repolarization
conduction defects, ventricular pre-excitation, long and
short QT interval and Brugada-like repolarization
Table-2. Demographic characteristics of athletes in
changes which may be the expression of underlying
the study.
cardiovascular disorders, notably inherited
cardiomyopathies or ion-channel diseases which may
predispose to SCD. (Biffi, Delise et al. 2013). No. Percent Mean / SD
Age (year) 23.30 ± 4.63
PATIENTS AND METHODS
BMI 24.19 ± 2.93
Subjects: Sex
The study included hundred subjects engaged in
competitive sports for duration not less than 3_4 years Males 100 100
and with training at least 3 days per week and at least
Governorate
one hour per day.
Alexandria 100 100
Inclusion criteria
Medical History
 Any type of sport, football or basketball, swimming,
weight lifting or running. They divided into two broad Hypertension 11 11
types: dynamic (isotonic) and static (isometric).
symptoms 9 9
 Age range 18 to 45 years
 Only males. Family History 1 1
Smoking 7 7
Tools of data collection:

The subjects in the study was subjected to Investigations

 ECG was done for all and examined for rate, rhythm,
History taking voltage, ST, QT and recording of any abnormality. A
Full history especially questioning for syncope or standard 12-lead ECG was performed on competitive
chest pain. Family history of sudden death or coronary athletes who are apparently normal in the supine
disease. position during quiet respiration and recorded at 25

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Samir Rafla et al
mm per second. The ECG tracing was obtained at
least 24 hours after the last athletic activity.
 Echocardiography was done for cases that are
suspicious. Echo measured LV size (diameters, mass
index), any valvular lesions, pulmonary hypertension
and right ventricular measurements.
Statistical analysis of the data:
Data were analyzed using software (SPSS 23).
Descriptive data was expressed in frequency and
percent and was analyzed using Chi-square test also
exact tests such Fisher exact and Monte Carlo was
applied to compare different groups. P value was
assumed to be significant at (0.05) with confidence
interval set at 95%.
RESULTS
During the period from 1/1/2015 to 1/10/2016, 100
athletes were screened by ECG. 54 played isotonic sport
while 46 were on isometric sport. According to the past
medical history: 11 (11%) patients were hypertensive,
9(9%) were symptomatic, 1 (1%) was with positive family
history for cardiac diseases and seven (7%) were
smokers.
Data given total then in isometric (static) group then
isotonic (dynamic) group then P value respectively: LV
hypertrophy by voltage criteria 18%, 24%, 10.9%, p
0.087. Early repolarization in 5%, 9.3%, 0%, P 0.06.
RSR' in V1 (and V2 in some cases) 14%, 20%, 6.5%, P
0.047. Inverted T 3%, 3.7%, 2%, P =1. Total ECG
changes of any form 43%, 59%, 23.9%, P 0.001. The
significance of finding more ECG changes in isometric
(static) athletes is not clear but clinically did not show any
effect. Correlation between the 18 athletes with ECG
LVH and echocardiography: only 5 of the 18 showed
increased diameters by echo but within accepted athletic
heart criteria. Two of body builders confessed of taking
doping drugs (male hormones) but no clinical abnormal
signs were detected. No long QT was found.
DISCUSSION
Sudden death in athletes is a major concern; the
predictors and value of prior investigations remain to be
settled. The work aims to study electrocardiograms
(ECG) in competitive athletes to define incidence of
abnormalities and any relevant associations.
During the period from 1/1/2015 to 1/10/2016, 100
athletes were screened by ECG, 54 played isotonic sport
while 46 were on isometric sport in Alexandria.
The mean age of athletes was 23.3 years,and the
mean BMI of athletes was 24.19.
We observed that (11%) athletes were hypertensive,
(9%) were with cardiac symptom, (1%) was with positive
family history for cardiac diseases and (7%) were
smokers.
12 leads ECG was done to all athletes: LVH by
voltage criteria were found in 18% of athletes, Early
476 |© 2017 Global Science Publishing Group, USA
Copyright@2017
repolarization in 5%, bradycardia in 6%,RBBB in 14%,
Inverted T in 3% and Sinus arrhythmia in 6% and we
observed that 43% of all athletes were with at least one
ECG changes ,while it was up to 60% of athletes as
described by Leite, Sérgio Machado.(Leite, Freitas et al.
2016).
The most commonly used voltage criterion for LVH is
the Sokolow-Lyon index. However, ECG QRS voltage
may not be a reliable predictor of LVH.
In athletes, intensive conditioning is also associated
with morphological cardiac changes of increased cavity
dimensions and wall thickness that are reflected on the
ECG. These changes constitute physiological LVH in
trained athletes and usually manifests as an isolated
increase in QRS amplitude,LVH are prevalent and
present in up to 18% of athletes. Drezner JA, Fischbach
P, Froelicher V, et al(Drezner, Ackerman et al. 2013)
reported that present in up to 45% of athletes. A high
prevalence of ECGs that fulfil Sokolow–Lyon voltage
criteria for LV hypertrophy has been consistently
reported in trained athletes assessed the prevalence and
type of ECG abnormalities in 1005 elite Italian athletes,
75% male who participated in 38 sporting
disciplines.(Biffi, Delise et al. 2013).
Early repolarization has traditionally been regarded
as an idiopathic and benign ECG phenomenon, with a
clear male preponderance. The early repolarization ECG
pattern is the rule rather than the exception among highly
trained athletes. The early repolarization ECG shows
elevation of the QRS–ST junction (J-point) of at least 0.1
mV from baseline, associated with notching or slurring of
the terminal QRS complex which may vary in location,
morphology, and degree. These changes often are
localized in precordial leads, with the greatest ST-
segment elevation in mid-to-lateral leads (V3–V4), but
maximal ST-segment displacement may also be seen in
lateral leads (V5, V6, I, and aVL), inferiorly (II, III, and
aVF), or anteriorly (V2–V3).
Early repolarisation is reported in up to 35–91% of
trained athletes and is more prevalent in young males
and black by Drezner JA, Fischbach P, Froelicher V, et
al.(Drezner, Ackerman et al. 2013), 50% to 80% of all
highly-trained athletes present have early repolarization
reported by Scharhag, Jürgen(Scharhag, Lollgen et al.
2013) and it was observed in 50–80% of resting ECGs
by Biffi, Alessandro(Biffi, Delise et al. 2013),and it was
less than 10% of the 15,000 participants reported by
Sinner, Moritz F(Sinner, Porthan et al. 2012),while it was
only in 5% of the athletes in our study.
The normal heart beat is initiated by the sinus node
which is located high in the right atrium near the junction
of the superior vena cava and the right atrial appendage.
To be classified as sinus rhythm, three criteria must be
met: (1) there must be a P wave before every QRS
complex, (2) there must be a QRS complex after every P
wave and (3) the P wave must have a normal axis in the
frontal plane (0–90°s). Assuming an intact sinus node,
the heart rate is set by the balance between the
sympathetic and parasympathetic nervous systems. In
healthy adults, sinus rhythm < 60 beats/min is
considered as ‘sinus bradycardia’.
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Samir Rafla et al Copyright@2017

Table-3. Relation between type sport with ECG changes.

Type sport
Total
Isotonic Isometric
ECG changes (n=100) χ2 p
(n=54) (n=46)
No. % No. % No. %
LVH
Absent 82 82.0 41 75.9 41 89.1
2.934 0.087
Present 18 18.0 13 24.1 5 10.9
Early repolarization
Absent 95 95.0 49 90.7 46 100.0
4.483 0.060
Present 5 5.0 5 9.3 0 0.0
HR<60
FE
Absent 94 94.0 48 88.9 46 100.0 p=
5.437*
Present 6 6.0 6 11.1 0 0.0 0.030*
Rsr'
Absent 86 86.0 43 79.6 43 93.5
3.957* 0.047*
Present 14 14.0 11 20.4 3 6.5
Inverted T
FE
Absent 97 97.0 52 96.3 45 97.8 p=
0.200
Present 3 3.0 2 3.7 1 2.0 1.000
Sinus arrh
FE
Absent 94 94.0 50 92.6 44 95.7 p=
0.412
Present 6 6.0 7 7.4 2 4.3 0.684
2: Chi square test
FE: Fisher Exact for Chi square test
*: Statistically significant at p ≤ 0.05

Figure-1. Percentage of ECG changes among athletes

In well-trained athletes, resting sinus bradycardia is a
common finding due to increased vagal tone, it was only
in 6% of the athletes in our study.
IRBBB is defined by a QRS duration <120 ms with an
RBBB pattern: terminal R wave in lead V1 (rsR’) and
wide terminal S wave in leads I and V6. IRBBB is
observed in up to 40% of highly trained athletes
according to Drezner JA, Fischbach P, Froelicher V, et
al.(Drezner, Ackerman et al. 2013) ,and incomplete right
bundle branch block (RBBB) was in 33% of the ethletes
in van Dijk, Gaby Pons(van Dijk, van der Kooi et al.
2014), 35% to 50% of athletes have an incomplete right
bundle branch block according to Scharhag,
Jürgen(Scharhag, Lollgen et al. 2013) and The
prevalence of incomplete right bundle branch block has
beene stimated to range from 35 to 50% in athletes as
written by Biffi, Alessandro(Biffi, Delise et al. 2013) ,while
it was 14% of the athletes in our study.
T-wave inversion is defined as >1 mm in depth in two
or more leads V2–V6, II and aVF, or I and aVL (excludes
III, aVR and V1).
T-wave inversion in inferior (II, III, aVF) and/or lateral
(I, aVL, V5–V6) leads must raise the suspicion of
ischaemic heart disease, cardiomyopathy, aortic valve

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Samir Rafla et al
disease, systemic hypertension, and LV non-compaction.
T-wave inversion listed as Abnormal and uncommon
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athletesvaccording to D'Silva, Andrew(D'Silva and
Sharma 2014) ,while it was only 1.4% as descriped by 2.
Biffi, Alessandro(Biffi, Delise et al. 2013), and it was in
5% of the athletes in our study.
The heart rate usually increases slightly during
inspiration and decreases slightly during expiration. This 3.
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Echocardiography was done in 15 players, increase in
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Follow up by telephone questionnaire was done for 7.
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8.
CONCLUSIONS
Now after determining ECG changes which are
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of athletes and pathological changes were not present in
young competitive athletes, so ECG is not indicated for
routine screening in athletes and only indicated for those
whom have symptoms as syncope or chest pain or
tachyarrhythmia. Athletes with ECG changes due to
cardiac adaptation to physical exertion should be
reassured that they can continue to participate in 10.
competitive sports without additional investigation, in the
absence of symptoms or a family history of cardiac
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Recommendations:
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 Careful assessment and follow up both clinically and
ECG changes in compititive athelets. 12.
 Routine ECG for all competitive athletes is not
recommended, it is only indicated if persons have
symptoms as syncope or chest pain or
tachyarrhythmia. 13.
Conflicts of Interest
Authors declare that there is no conflict of interests
regarding the publication of this paper.
478 |© 2017 Global Science Publishing Group, USA
Copyright@2017
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